Orthopedic Coding Alert

Question: An established patient presents with cervical spinal stenosis C5-C6 and degenerative disc disease with myelopathy and radiculopathy; during the office evaluation and management (E/M) service, the surgeon and patient decided that they would treat the injury with surgery. Notes indicate that the E/M consisted of moderate-level medical decision making (MDM) and took 45 minutes. What CPT^® and ICD-10 code(s) would you choose for this encounter?

Kentucky Subscriber

Answer: You’ll need three diagnosis codes to represent this patient’s injuries: one each for the myelopathy and radiculopathy, preceded by a code for spinal stenosis (since the stenosis is what prompted the surgery). You would report the following diagnosis codes:

• M48.02 (Spinal stenosis, cervical region) as the primary diagnosis to represent the primary problem.
• M50.022 (Cervical disc disorder at C5-C6 level with myelopathy) for the myelopathy.
• M50.122 (Cervical disc disorder at C5-C6 level with radiculopathy) for the radiculopathy.

For the E/M, the optimal code choice is 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.)